HomeMy WebLinkAboutBLDG-25-126 :;i`' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Fri j`1; _6° CITY IGCY"CY 0 1./+I) MA DATE 3^ 2 --1 PERMIT#Q O G. 2--/Zh
JOBSITE ADDRESS 12 (1-1 Mr t('t 13 6 r<5 OWNER'S NAME V )ec(4^ ,e-
GOWNER ADDRESS TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL ElEDUCATIONAL illRESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS—I BSM 1 ? 3 4 5 6 7 _ 8 9 10 'I'I 12 '13 14
BOILER
BOOSTER 1
CONVERSION BURNER !
COOK STOVE
DIRECT VENT HEATER '
DRYER
FIREPLACE i
FRYOLATOR
FURNACE
GENERATOR 1 1
GRILLE
INFRARED HEATER -�
LABORATORY COCKS I
MAKEUP AIR UNIT ____I
OVEN !
POOL HEATER •
ROOM/SPACE HEATER
ROOF TOP UNIT _�_
TEST --V .. -
UNIT HEATER
•
UNVENTED ROOM HEATER ��
WATER HEATER
OTHER
1
I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERACE BY CHECKING THE APPROPRIATE BOX BELOW
• LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑
l
OWNER'S INSURANCE WAIVER: l am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
"i:• I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
`— and that all plumbing work and installations performed under the permit issued for this application will be in comps' nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the G ral Laws.
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PLUMBE 3ASFITTER NAME JO'V LICE. #
z(7 'IGNATURE
MP I MGF❑ JP ❑ JGF❑ LPG' ❑ CORPORATION [Id PARTNERSHIP 1 I� SH P❑4r LLC❑n
COMPANY NAME J T L c)ki.I1V1 ( V�y ADDRESS
CITY 1�'�VP an d Lt_ tt STATEfj M . ZIP o 2 a 4 TEL,50 c) 3-7 3).11
FAX CELL g" EMAIL V A.. ()L- W 1 wet 54f 7 Q c2,04►, ,e L0l77
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
•
FEE: u PERMIT#
PLAN REVIEW NOTES